Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.

Monday, February 27, 2012

Mental Health, Military Style-- Guest Blogger Dr. Jesse Hellman

Today, we're talking about mental health and the military. But first, I just learned, via Facebook, that today is International Polar Bear Day. If you have one, hug him tight. Make sure he's been fed first.

Over on his own blog, Pete Earley, has a post up about a veteran who was about to kill himself with a homemade gun. He called a Suicide Hotline, the police were sent and the patient was charged with possessing a homemade gun. It's a good post, worth the read, and Earley brings up issues about mental health emergencies and the legal system that aren't limited to veterans.

Yesterday, the New York Times had an article about military discharges for a diagnosis of "personality disorder." The diagnosis is presumed to be a pre-existing one, so once a soldier is diagnosed with a personality disorder, he can be discharged without the usual military benefits. I know that our guest blogger Dr. Jesse Hellman has an interest in the topic. He spent two years as a military psychiatrist, and has attended hearings on the topic, so I asked him to do a quick guest post for us:

Jesse writes: The article tells of a 50 year old woman psychologist who enlisted, was sent to Afghanistan, and was involved in a number of incidents, eventually being accused of sexual harassment for remarks she had made. She was sent for psychiatric evaluation and was given the diagnosis of personality order on discharge. There are severe consequences of this diagnosis, which can include loss of future benefits, medical expenses, and more. Was the diagnosis properly considered? Did her commanding officer ask that she be given that diagnosis in order to reduce the huge medical expenses produced by the military?

This is not the first time I had heard of this problem. In the fall, I attended in Washington a meeting of the House Committee for Veteran Affairs. Joshua Kors, a writer who had several pieces in The Nation which addressed this very problem, was testifying along with a soldier who had been discharged as having a personality disorder. The Department of Defense sent several people to testify that there was no abuse of the diagnosis.

One of Mr. Kors's strongest points was the sheer number of personality disorder diagnoses that were being made. It looked like these were occurring at two bases in the United States that processed discharged soldiers: Could it possibly be that this number of applicants slipped through the initial screening process?

My own impressions were mixed. It seemed inconceivable to me that any military commander would directly order physicians to misdiagnose in order to reduce costs to another entity. Vastly too great a risk to him, and to what advantage? On the other hand, the diagnosis as described in the DSM is more severe than the problem warrants: it is possible that many soldiers enlisted thinking the military was for them but then, through various routes, found that life in Afghanistan, under fire, with all the dangers and rigors, was too much. Their attitudes disintegrated. They wanted out. They were poor soldiers who disrupted morale.

To those who understand how to use bureaucracy to effect one's ends, direct orders are not needed. If it takes one hour to examine a soldier and find a given diagnosis, but alternate diagnoses require much more paperwork, repeat examinations, record reviews, etc, and the caseload of the examiner is sufficiently great, is it not predictable that the particular diagnosis that minimizes work will increase in comparison to the alternatives?

So what do you think? There are many issues here worthy of discussion.

Horrified the discussion is about would people really do this and not about how people with personality disorder are viewed as broken and unfixable beyond repair.

31,000 people dumped out of the military since 2001 - left with no benefits or help and a black mark getting in the way of possible future employment.

I knew personality disorder dx caused stumbling blocks in getting treatment (docs wont take patients, insurance wont pay) I had no idea how badly the dx screw over a persons life (even without the real issues of living with such a dx)

@Horrified: I don't think the discussion is about whether people with this diagnosis are broken beyond repair. What I recall from the hearing is that Kors alleged that the motive for the diagnosis was to save a great deal of money and that the diagnosis was being (or had been) improperly applied. The soldier he brought to the hearing had experienced a shell exploding near his head and had a number of symptoms as a result. From what I recall he had been expected to return to duty, with a good attitude, but had not been able to do that. He became suicidal (his explanation) and was then kept in solitary confinement in closet in a guard station until further arrangements were made. He was given the diagnosis of personality disorder, although there was no prior history to substantiate it.

The military did not address his case in particular, but it was clear that they thought that soldiers exploited psychiatry in order to get sent back to the states. I think they would have said that he was kept in the guard station for his own protection and that no other options were available where he was.

Perhaps there is a problem with the concept of personality disorders- as something that is fixed in a person. I think that the personality that is expressed is always contextual- and maybe someone can present as meeting the criteria for the disorder at one time and place, and not in another.

Not to mention that when people are under lots of stress, (say, when they are IN A WAR ZONE...) they are going to start reverting to maladaptive coping mechanisms that in many cases will look a lot like or even meet full criteria for personality disorders. I think an argument could be made that while the military didn't initially cause these individual's bad coping mechanisms, they most certainly did trigger their expression in a large number of cases.

ARGH. According to the LCSW I saw today for over an hour, at the county's mental health facility . . . . I told her my therapist says PARTIAL, that he says I don't fit it all. She took that, but still stuck with it.

On the whole, I actually really liked her; she was the antithesis of my last shrink, and made me feel like maybe all female mental health providers aren't bad after all (yup, major overgeneralizing there but I do have mother issues lol).

Still, now I know what it's like to feel pigeon-holed and I don't like it. Why don't I feel pigeon-holed by my other diagnoses? Sometimes I do, but the reluctance to diagnose that annoys me about my psychologist also leads me to look beyond the labels, too.

I don't know entirely how I feel about this; I've only been home 20 minutes, just long enough to write a blog post about how I don't think replacing psychiatrists with prescribing psychiatric nurses is appropriate, they should supplement the doctor not replace.

This sucks. Am I any different than I was before she put this label on me? I'm not a different person, but my experiences with mental health care might change . . . if providers treat me with stigma, which the LCSW assured me that everyone there is used to patients with borderline, that half their patients have it (she amended that though, as if feeling it was too much of a stereotype, at least that's how it seemed to me), that the people there treat it like one more piece of info you know about the patient rather than with stigma . . . that it informs them as to treatment . . . isn't there little to no treatment?

DBT, possibly? But that's a group therapy and I'm not in group therapy.

Anyway. Labels suck, whether they're appropriately given or not. I don't know if this one is or not.

I say the problem is that they take benefits away period. If someone is high functioning enough to get through basic and make it into a warzone they should get benefits. If it is not discovered in basic it is not pre exsisting end of discussion. If something happens mentally it is something the military needs to pay for. it is simply a cost of war on the human body....as much as any other combat injury.

Jane: the time-saving theory is Jesse's theory. He may be right, but it's not something official.

It seems to me that the military might do a better job screening for personality disorders, and that there should be a statute of limitations beyond which they can't use it as a reason for discharge without benefits. It seems to me that if someone has worked in close and stressful quarters for 2 years without incident or censure, then they don't have a personality disorder. And certainly, someone whom the military could tolerate for 5-7 years can't be so "personality disordered" as to be unemployable. The diagnosis requires that it be present in a variety of situations, not just war zones.

Rob: I never claimed that psych labels aren't used to punish people, but they shouldn't be. I would like my happy idealism to be left intact, thank you.

sarebear, it sounds like ur psychologist does not believe ur borderline, and the lcsw agrees u do not meet the criteria. because partial borderline does not sound legit and is probably not in the dsm, i encourage u to challenge the lcsw

Something jumped out at me in the NY Times article that made me wonder about the accuracy of the reporting:

Vietnam Veterans of America sued the Defense Department for the unfair dx. and d/c for "personality disorder or adjustment disorder." Seems to me (I'm a psychologist) that an adjustment disorder is the polar opposite of a personality disorder in that it precludes a preexisting condition, is transient, and is a reaction to a traumatic situation. I often use that dx. so as not to stigmatize a pt.

Military psychiatrist here. I've served with three Marine commands, one of them in Afghanistan. WAY prior to that, I was an active duty Marine for six years. Thirteen years total military service: seven as a shrink.

Tons of personality disorders in the military. The military attracts a lot of broken souls. Heck, it's practically part of the recruiting narrative...that you can be "re-born" as a Marine or soldier (why would someone need to be "re-born"? think about why that message attracts enlistees). Lots of sociopathy. Lots of borderlines. Quite more schizoid than you'd imagine. Some of this is the predominant age group, 18-22, where a lot of people are simply still adolescents--psychologically. The military leadership (who has self-selected to live/breathe the military culture these kids are often rejecting) are NOT very tolerable of young troubled kids who are still working out their mommy/daddy issues. Needless to say, there are a lot of bad fits, and many manifest with psychological symptoms that best fit a PD diagnosis (a good handful of these end up with a PDNOS diagnosis).

And listen...it's not that they're unfixable...it's that the Marine Corps (in my case) is not a place for troubled youth to get years of counseling to un-do their childhoods or whatever. It's simply not our mission (though some days it feels like it is).